Provider Demographics
NPI:1245423110
Name:GOMEZ, TARA A (RN SFA)
Entity Type:Individual
Prefix:MRS
First Name:TARA
Middle Name:A
Last Name:GOMEZ
Suffix:
Gender:F
Credentials:RN SFA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2300 E 30TH ST BLDG D STE 101
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:87401-8990
Mailing Address - Country:US
Mailing Address - Phone:505-327-1400
Mailing Address - Fax:505-564-3202
Practice Address - Street 1:2300 E 30TH ST BLDG D STE 101
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:NM
Practice Address - Zip Code:87401-8990
Practice Address - Country:US
Practice Address - Phone:505-327-1400
Practice Address - Fax:505-564-3202
Is Sole Proprietor?:No
Enumeration Date:2007-08-23
Last Update Date:2008-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMR52863163WX0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WX0800XNursing Service ProvidersRegistered NurseOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM47522Medicaid
NM00NM006H18OtherBCBS
NM10034667OtherLOVELACE
NMR52863OtherNEW MEXICO BOARD OF NURSI